Provider Demographics
NPI:1255951216
Name:PETTY, MICHAEL GLENN (RN, ACNS-BC, CCNS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GLENN
Last Name:PETTY
Suffix:
Gender:M
Credentials:RN, ACNS-BC, CCNS
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7615 XERXES AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3546
Mailing Address - Country:US
Mailing Address - Phone:612-273-5607
Mailing Address - Fax:612-273-9966
Practice Address - Street 1:500 HARVARD ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:612-273-5607
Practice Address - Fax:612-273-9966
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN095570163WC0200X
MN71364SC0200X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine